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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. d <br /> Telephone (209} 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> t <br /> } Application is hereby made to the San Joaquin Local Hed�th,'District for:-a permit to construct and/or install the work herein <br /> described. This applicati is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump <br /> and-the Rules and Regulatio of the San Joaquin Local Health District, <br /> Job Address [ / - 6 1' Subdivision Name �11T[} <br /> Owner's Name AM-5r7 �� 5� Address I 7, i�ii9G Phone <br /> Contractor's Name �l.i License No. Z2 ; Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL `�] WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTRLLRTION ;,-] »-tFSYSTf-M RFP IIR­E- OTHER U <br /> DISTANCE TO NEAREST: ,SEPTIC TANK t SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE �« ECIFIC �..,,�,�._,._._..— <br /> TYPE OF WELL PROBLEMARCA-- CONSTRUCTION SnECIFICAT[ONS <br /> J Industrial U Open Bottom Manteca Dia, of Well Excavation tib. { <br /> ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> 1-7 Public Other Delta <br /> Type of Casing <br /> L i Irrigation Approx. Eastern <br /> Specifications <br /> Depth . +t <br /> Catliadie Protection De P � l <br /> I Depth of Grout Seal <br /> Geophysical , <br /> Type of Grout <br /> LJ Other..y Surface Seal Installed by <br /> Repair Work Done Ef Type of Pump HIP. f i # ,•)State Work Done <br /> Well Destruction U Well Diameter !Sealing Material (topf50, <br /> Depth t.-FilIer�Material (Below 501 <br /> [ �,y f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITIONS i No septic tank or seepage pit.permitted if 1 <br /> U ( p g p p public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial; ., .Other <br /> Number of living units: —h— Number of bed roams Lot size -�.---� �— <br /> Character of soil to a depth of 3 feet:' _s A n Water table depth <br /> SEPTIC TANK Type/MfgI�s + 41 Capacity __ No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg ,.,_' i ' ',Capacity Method of Disposal' i <br /> SEWAGE SYSTEM t <br /> Distance to nearest: l+lel]�,="'2�F.punfdation Property Line <br /> DESTRUCTION ❑ r y s <br /> LEACHING LINE No. & Length of lines [7 'Total ?length/size �r <br /> FILTER BED Distance to nearest: Well Founda�tl,on'" .-+Property Line <br /> SEEPAGE PITS 71 Depth Size :+ -. Number 1 <br /> SUMPS L— Distance to nearest: Well Foundation , Property Line ' <br /> DISPOSAL PONDS ? <br /> I hereby certify that I have iprepared this application_and that the work will be±.done n ,accbrdance with,San Joaquin county <br /> ordinances, state laws, and rules and regulations 5f the:San ]oaquin Local Health Distract.. <br /> Home owner or licensed agent's signature certifies the fol'l`owing: "I certify that ir).the'performan'e� of;the work for which this <br /> permit is issued, 1 shall not'employ any person in such manner as to become subject to workUr� compensation laws of California." <br /> Contractor's hiring or sub-coifitracting-signature certifies the following:)"I certify that in 'the performance of the work for which' <br /> this permit is .issued, I shall' employ persons subject to,workman's compensation laws of'Califoriia." ' <br /> The applicant must cal for a < requir d inspections. Complete drawing on reverse side, � h ss <br /> Signed X f / Title: 'LE.'L� Date: �I — �'� <br /> !. F R DE TMENT USE ONLY <br /> Application Accepted by, Area 07 ,Stk 466-6781 L <br /> Additional Comments: % ` E;Lodi 369-3621 P <br /> Pit or Grout Lnspec'tio9-1 Date �' Manteca 823-7104 <br /> Final Insp� on by Date {� Tracy 835-6385 <br /> Applicant - Return all copies to: Environmenta •Health Permit/Services 1601 E. Hazelton Ave„ P,',0. Box 2009, Stk., CA 45201 <br /> FEE BASE i-.AMOUNT-DUE ri AMOUNT REMIZTJ=() RECEIVED B_Y DATE f PERMIT N0. <br /> INFO _ <br /> i <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />